2015-10-23_REPORT - M1980201

• Permit No: M1980201
• IBM Index Class Name: REPORT
• Doc Date: 10/23/2015
• Doc Name: Annual Fee, Report,Map
• From: Marthias Concrete Inc.
• To: DRMS
• Email Name: THM
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee contact information. If this inforrnation is not current, please type or print
current contact information:
Permittee Contact:
Thomas G. Mathias
Permittee Company:
Mathias Concrete Inc
Address:
1500 N. Farm Rd.
P.O. Box 266
Monte Vista, CO 81144
Phone Number:
[phone]
Fax Number:
[phone]
Email Address:
I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
Signature of
M -AF -01
10— — -
or Documented Designee Date